Texter v. Department of Human Services
Texter v. Department of Human Services
Opinion of the Court
The opinion of the Court was delivered by
The issue in this case is whether administrative regulations, valid when promulgated, have been rendered invalid by changing conditions. More specifically, the question concerns the effect of eighteen years of inflation on regulations of the Department of Human Services that determine income eligibility requirements for receipt of Medical Assistance for the Aged. We remand to the Commissioner to consider the matter as a petition to amend the regulation setting the income eligibility requirements.
I
Plaintiffs are six individuals who have been receiving home health benefits under New Jersey’s Medical Assistance for the Aged program. N.J.S.A. 44:7-76 to -84 (Supp. 1981) (MAA). Before July 1980, each plaintiff was a New Jersey resident, age 65 or over, not eligible for Medicaid and with insufficient income and resources to pay for health services covered by the MAA program. Each, therefore, was eligible to participate in MAA.
Plaintiffs are joined by common bonds of old age, failing health and indigency. For example, plaintiff Frank Coppola is 79 years old and lives with his wife of about the same age. He has cardiac and prostate ailments requiring care 24 hours per
On July 1, 1980 each plaintiff received a 14.37% increase in Social Security benefits. This increase caused each plaintiffs monthly income to exceed MAA’s income eligibility standard contained in N.J.A.C. 10:83-6.5. Although the increase was intended to help beneficiaries to keep pace with inflation, it generated the opposite effect on plaintiffs. By forcing discontinuance of MAA benefits, plaintiffs were made individually responsible for their medical costs. Those costs will consume most of the income of some plaintiffs; for others, the costs will exceed their income.
Plaintiffs exercised their right to a hearing, at which the only issue was whether their increased income made them ineligible for MAA. At the hearing, plaintiffs challenged the validity of the income eligibility standard in N.J.A.C. 10:83-6.5. They alleged that, since 1963 when the regulation was promulgated, the effect of inflation was to render the income limit so low as to be arbitrary and capricious. In effect, plaintiffs sought to raise the income standard to reflect financial need under current economic conditions.
In upholding the termination of each plaintiff’s MAA benefits, the Administrative Law Judge (ALJ) did not discuss the effect of inflation on the income eligibility standard. Noting that the standards were determined at the discretion of the Commissioner, the AU suggested that any complaints concerning income requirements should be directed to the Commissioner. The Department adopted the ALJ’s decisions as its final rulings.
Plaintiffs appealed to the Appellate Division, which reversed and remanded the matters to the ALJ to consider the merits of plaintiffs’ challenge to the continuing validity of the standard. That court stated “slavish adherence” to a 17-year-old income eligibility standard “may not be in overall furtherance of [legislative] policy.” 178 N.J.Super. 104, 108 (1981).
II
The second half of this century has witnessed increasing attention to health care for the needy, particularly the aged. The problem is complex and has produced overlapping and sometimes conflicting solutions from state and federal officials.
Before enacting Medicare and Medicaid, the federal government partially funded medical care to the needy aged under the Kerr-Mills program. 42 U.S.C.A. § 301 et seq. (repealed 1974). To participate in the Kerr-Mills program, New Jersey established MAA in 1962. L. 1962, c. 222. The original Act provided financial assistance to any New Jersey resident over age 65 who was not a recipient of old age assistance and whose income and resources were insufficient to meet the costs of health services. Id. at § 1. The Commissioner was given the authority to issue regulations implementing the Act, including authority to determine the need for medical assistance based on the “income and resources of the aged individual making due allowance for a minimum standard of living compatible with decency and health.” Id. at § 6(c). In 1963, the Commissioner exercised that authority and issued the income eligibility standard contained in N.J.A.C. 10:83-6.5.
In 1965, Congress replaced this part of the Kerr-Mills program with Medicare, 42 U.S.C.A. § 1395 et seq. (1974 & Supp. 1981), and Medicaid, 42 U.S.C.A. § 1396 et seq. (1974 & Supp. 1981). To qualify for matching federal Medicaid funds, states were required to provide medical assistance for the categorically needy: those receiving old age assistance, the blind, families with dependent children and the permanently and totally dis
Because extension of Medicaid to all medically needy persons was considered too costly, the Legislature chose not to include all MAA beneficiaries in its Medicaid plan. See Assembly Committee on Institutions and Welfare, Medical Care for Low Income Persons in New Jersey 15 (Sept. 10, 1968). Instead, it chose to transfer as many MAA recipients as possible to the Medicaid program. Although not obliged to provide additional funds, the Legislature continued the MAA program for those elderly needy whose income disqualified them from the Medicaid program. See id. at 16. In 1969, therefore, the Legislature amended MAA to apply to people age 65 or over who cannot pay for medical services, but who are ineligible for Medicaid. L. 1969, c. 227, § 1, N.J.S.A. 44:7-76 (Supp. 1981). Nonetheless, the Commissioner retained the 1963 MAA income eligibility standard, which has remained unchanged. Consequently, the maximum monthly income allowed a non-institutionalized participant is higher under MAA than under Medicaid: $500 per month under MAA, but only $261 per month under Medicaid. Compare N.J.A.C. 10:83-6.5 with N.J.A.C. 10:94-4.3.
Ill
Judicial review of administrative action is a limited inquiry into whether the action is arbitrary, capricious and unreasonable or unsupported by substantial credible evidence. Henry v. Rahway State Prison, 81 N.J. 571, 579-580 (1980). This limited review prevents the courts from usurping policy decisions from other branches of government. See Newark v.
The income eligibility standards are set forth in administrative regulations; in effect, plaintiffs seek to amend the regulations by increasing the income eligibility standard. They present statistics showing that prices have more than doubled since 1963, substantially eroding plaintiffs’ ability to pay for urgently needed services.
At the time plaintiffs challenged the income eligibility requirement, the only available procedure was an adjudicatory proceeding. Recent amendments to the Administrative Procedure Act (APA), however, permit plaintiffs to petition to amend the rule setting the income eligibility standard. L. 1981, c. 27, § 11(f) (amending N.J.S.A. 52:14B-4).
Administrative agencies have wide discretion in selecting the means to fulfill the duties that the Legislature delegated to them. Agencies may act informally, Shapiro, “The Choice of
Classification of agency action, though easy in theory, is often difficult to apply in specific cases. See Cunningham v. Department of Civil Service, 69 N.J. 13, 20 (1975); Boller Beverages, Inc., supra, 38 N.J. at 154; Shapiro, “Rulemaking or Adjudication,” 78 Harv.L.Rev. at 924. Compare Anaconda Co. v. Ruckelshaus, 352 F.Supp. 697, 702 (D.Colo. 1972) (individualized rule-making requires evidentiary hearing) with id., 482 F.2d 1301, 1306-1307 (10 Cir. 1973) (APA notice and comment procedure sufficient for individualized rulemaking). New Jersey’s APA, N.J.S.A. 52:14B-1 to -15 (1970 & Supp. 1981) as amended, L. 1981, c. 27, separates formal agency action into administrative adjudication and rulemaking.
Adjudicatory proceedings usually determine the legal rights and relations of specific individuals, see Bally Mfg. Corp., supra, 85 N.J. at 340; Shapiro, “Rulemaking or Adjudication,” 78 Harv.L.Rev. at 924, 930, or a limited group of individuals. N.J.A.C. 1:1 — 6(a)(iii). These determinations often involve disputed factual issues, see Bally Mfg. Corp., supra, 85 N.J. at 340; Cunningham, supra, 69 N.J. at 23; N.J.A.C. l:l-1.5(a)(3), and require evidence and cross-examination in an adversary proceeding for proper resolution. N.J.S.A. 52:14B-9(c), -10(a) (1970 & Supp. 1981).
Typically, adjudicatory hearings are what the APA calls “contested cases”. N.J.S.A. 52:14B-2(b). But the terms are not coextensive. Contested cases are those in which the Constitution or a statute requires an adjudicatory hearing. Id. Adjudicatory hearings may be granted at the discretion of the agency in other circumstances. See In re Orange Savings Bank, 172
Generally, administrative rulemaking proceedings involve broader policy judgments. These proceedings seek to develop facts through investigation so that rules of prospective application may be developed. See Boller Beverages, Inc., supra, 38 N.J. at 151-152; Shapiro, “Rulemaking or Adjudication,” 78 Harv.L.Rev. at 935. Although rules generally apply to a large class of individuals, rules that affect specific parties are nonetheless valid if enough other characteristics of rulemaking are present. See Bally Mfg. Corp., supra, 85 N.J. at 343; Cunningham, supra, 69 N.J. at 22; Shapiro, “Rulemaking or Adjudication,” 78 Harv.L.Rev. at 924.
Administrative agencies possess the ability to be flexible and responsive to changing conditions. See Heir v. Degnan, 82 N.J. 109, 121 (1980). This flexibility includes the ability to select those procedures most appropriate to enable the agency to implement legislative policy. See N.J.S.A. 52:14F-7(a) (Supp. 1981). Therefore, agencies sometimes develop hybrid proceedings possessing characteristics of both adjudication and rulemaking. See Cunningham, supra, 69 N.J. at 21 (public utility ratemaking procedures, although quasi-legislative in origin, are conducted like quasi-judicial proceedings); N.J.A.C. 1:1 — 1.6(a)(3). In fact, courts and commentators have encouraged hybrid agency proceedings as a way of producing more reasoned agency decisions, especially in complex and controversial policy areas. See, e.g., International Harvester Co. v. Ruckelshaus, 478 F.2d 615, 649 (D.C.Cir. 1973); id. at 651-652 (Bazelon, C. J., concurring); Bazelon, “Coping with Technology Through the Legal Process”, 62 Cornell L.Rev. 817, 824-826 (1977); Stewart, “Vermont Yankee and the Evolution of Administrative Procedure,” 91 Harv.L.Rev. 1805, 1812-1814 (1978).
The choice of proceedings, however, rests within the discretion of the agency. Courts normally defer to that choice so long as
Our dissenting colleague agrees that the responsibility for determining the scope of MAA benefits rests with the Legislature. Post at 391. The Legislature has determined that the right to MAA benefits is not absolute, but is “[sjubject to the provisions of this act”. N.J.S.A. 44:7-76.
IV
One measure of the validity of an administrative regulation is whether it is consistent with the expressed policy of the enabling statute and related legislation. See Guttenberg Savings & Loan Ass’n v. Rivera, 85 N.J. 617, 624 (1981); New Jersey Guild of Hearing Aid Dispensers v. Long, 75 N.J. 544, 561-562 (1978). In evaluating plaintiffs’ claims, the Commissioner should consider changes in state policy manifesting renewed concern for the elderly. Since 1963, when the Commissioner issued the income eligibility standard, the New Jersey Legislature has manifested increasing interest in the well-being of its elderly residents.
In 1971, the Legislature found that many elderly are isolated, economically deprived and ill-prepared to cope with the change in family relationships. N.J.S.A. 40:23-6.38(c) (Supp. 1981). Consequently, the Legislature expressed a desire to help the elderly grow old with dignity and independence. Id. at (d). To effectuate this policy, the Legislature established a Division on
The interaction between the Medicaid and MAA maximum income eligibility standards, however, appears to undermine the federal and state policy of encouraging independence for the elderly. For example, to qualify for the maximum Medicaid allowance, $714, a recipient must enter an “approved facility”, e.g., a hospital or nursing home. N.J.A.C. 10:94-4.33, Table A. By contrast, the maximum MAA allowance, $500, is provided to recipients who receive their health care at home. N.J.A.C. 10:83-6.5. As a result, the interaction of MAA and Medicaid encourages MAA recipients with incomes between $500 and $714, such as plaintiffs, to enter approved facilities where the cost of maintenance is higher than the cost of health care at home. That result fosters the removal of elderly people from their families and their placement, at greater public expense, in institutions. Compassion and economy protest that bitter irony.
We recognize that the Commissioner is duty bound to consider the availability of funds for any increase in the MAA income eligibility standard. Therefore, the economic costs of the regulation are relevant on remand. In this regard, the Commissioner should explore the number of medically needy elderly who would be added to the MAA program and the estimated increased costs to the State if the income eligibility standard were increased. The Commissioner should also consider, however, the current regulation’s economic impact on the recipients. L. 1981, e. 27, § 2 (amending N.J.S.A. 52:14B-4 to require agency statement of socio-economic impact of proposed rules). See 13 N.J.R. 177, supra. Cf. N.J.S.A. 52:13F-1 to -5 (Supp. 1981) (requiring determination of the long and short term economic effects of proposed legislation on those against whom it is directed). Obviously, the Commissioner should also consider any other factor that he deems appropriate. In remanding, we recognize the difficult decisions confronting the Commissioner and the Legislature in trying, in a time of increasing costs, to continue essential human services with constant, or even reduced funds. The ultimate determination of the income eligibility standard is a legislative and administrative judgment, subject to judicial review. On review, a court is obliged to accord a presumption of validity to an administrative regulation, and the burden is on the challenger to demonstrate that the regulation is arbitrary, capricious and unreasonable. New Jersey Guild of Hearing Aid Dispensers v. Long, supra, 75 N.J. at 561. In assessing the validity of a regulation, a court is not free to substitute its judgment for the expertise of the agency. Id. at 562. Because we are remanding the matter to the Commissioner, we need not determine the validity of the challenged regulations at this time.
We affirm and modify by remanding these matters to the Commissioner for further proceedings consistent with this opin
The following chart demonstrates the relationship of each plaintiffs income to cost of MAA services.
Texter $673.40 $592.58
McNinney, B. & W. 663.60 718.10
Boyd 648.70 413.05
Ciccone 511.50 419.00
Matthews 702.00 592.58
Coppola 609.00 915.72.
Under Medicaid the income eligibility standard for a particular applicant depends upon the participant’s living arrangements. See N.J.A.C. 10:94-4.33, Table A. Under MAA the standard depends upon the participant’s marital status. See N.J.A.C. 10:83-6.5.
Plaintiffs used the Consumer Price Index (CPI) to show the effects of inflation. The CPI uses 1967 as its base year, valuing that year’s prices at 100. According to CPI, prices in 1963 equalled 91.9; in July 1980 they equalled 247.8.
In its entirety, the section reads:
Subject to the provisions of this act, any resident of New Jersey who has attained the age of 65 years, who is not eligible to receive medical assistance pursuant to chapter 413 of the laws of 1968, and whose income and resources are insufficient to meet the costs of health services provided under this act, shall be entitled to receive medical assistance for the aged.
Dissenting Opinion
dissenting.
The issue here is the continued validity of eligibility standards for Medical Assistance for the Aged (MAA) promulgated by the Department of Human Services in 1963 and not adjusted for inflation since then. The majority remands to the Commissioner to consider amending the regulations, directing him to take into account the medical needs of the plaintiffs, the economic costs of the program and “any other factors that he deems appropriate.” (at 381) I agree that these regulations need serious re-evaluation. However, contrary to the majority, I would hold the regulations facially invalid. I would remand only for the purpose of drafting new regulations consistent with the statute, N.J.S.A. 44:7-76 to -84.
The MAA statute sets forth a clear and unambiguous entitlement to medical assistance. “Subject to the provisions of this act, any resident of New Jersey [over 65 years old and ineligible for Medicaid], whose income and resources are insufficient to meet the costs of health services provided under this act, shall be entitled to receive medical assistance for the aged.” N.J.S.A. 44:7-76 (emphasis added). In implementing this entitlement, the Commissioner is directed
[t]o provide that, in determining need for medical assistance for the aged and the amount of such assistance to be granted, there shall be taken into consideration all other income and resources of the aged individual, making due allowance for a minimum standard of living compatible with decency and health. [N.J.S.A. 44:7-81(c) (emphasis added) ]
There can be no confusion about the meaning of these provisions. Any eligible person who needs MAA services and cannot reasonably afford them must be provided such services.
Expressing concern for the economic difficulties faced by the State, the majority suggests that “the economic costs of the regulation are relevant on remand,” at 389. But it is the role of the Legislature to weigh the cost of assistance against the social obligation to care for those unable to provide for themselves, and it has clearly resolved the issue in favor of assistance. The Director is legally bound to set the assistance at a level that provides a “minimum standard of living compatible with decency and health.” N.J.S.A. 44:7-81(c). He may not contravene this clear legislative entitlement. To the extent that the Commissioner argues otherwise, and to the extent that the majority
The record before us clearly demonstrates that the challenged eligibility standards are contrary to the MAA statute. For two of the plaintiffs here, the monthly cost of necessary medical services covered by MAA actually exceeds their total monthly income. Two others would have less than $100 per month remaining for necessities such as food and rent. See at 379, n.l. It would hardly be an overextension of judicial notice for us to conclude that minus $306.72 (Coppola) or even $92.50 (Ciccone) is an inadequate monthly income “for a minimum standard of living compatible with decency and health.” N.J. S.A. 44:7-81(c). Yet, both of these plaintiffs are ineligible for MAA under the current eligibility criteria.
The record further shows that the MAA eligibility standards have remained unchanged since 1963, even though prices have more than doubled since then. It strains credulity to the limit to suggest that the 1963 standard was so generous that it has survived the ravages of inflation. The clear evidence shows that those standards are, in 1982, so stingy that they bear no relation whatever to any minimum standard of living, much less one which reflects decency and health.
For these reasons, I would hold the challenged eligibility criteria invalid on their face. They are contrary to a clear legislative enactment and are therefore illegal. Chamber of Commerce, supra.
Plaintiffs here are elderly, indigent, and of failing health. They are among the most vulnerable persons in our society. The New Jersey Legislature has repeatedly manifésted its beneficent concern for the well-being of the elderly members of our community. At 387-388. The MAA program is a worthy reflection of that concern. By establishing unduly parsimonious eligibility criteria, the Commissioner has undermined this necessary humanitarian program. But it is not the Commissioner’s privilege to lower the statutory criteria. It is his duty to obey the law.
For affirmance and modification — Chief Justice WILENTZ and Justices CLIFFORD, SCHREIBER, HANDLER, POLLOCK and O’HERN — 6.
Dissen ting — J ustice PASHMAN — 1.
To justify its position that the Commissioner can set standards which contravene the above-cited portion of N.J.S.A. 44:7-81(c), the majority relies
The Majority reads N.J.S.A. 44:7-81(c) as the provision granting discretion to the Commissioner. In fact, N.J.S.A. 44:7-81(c) unequivocally directs the Commissioner to set eligibility standards “making due allowance for a minimum standard of living compatible with decency and health.” The act does not merely suggest that the Commissioner set such standards in his discretion: it directs him to act in accord with the statutory criteria.
Reference
- Full Case Name
- WILLIAM TEXTER, INDIVIDUALLY AND ON BEHALF OF ALL OTHERS SIMILARLY SITUATED, RESPONDENT AND CROSS-APPELLANT, v. DEPARTMENT OF HUMAN SERVICES, ANN KLEIN, COMMISSIONER; DIVISION OF PUBLIC WELFARE, G. THOMAS RITI, DIRECTOR, APPELLANTS AND CROSS-RESPONDENTS; BERTHA & WILLIAM McNINNEY, INDIVIDUALLY AND ON BEHALF OF ALL OTHERS SIMILARLY SITUATED, RESPONDENTS AND CROSS-APPELLANTS, v. DEPARTMENT OF HUMAN SERVICES, ANN KLEIN, COMMISSIONER; DIVISION OF PUBLIC WELFARE, G. THOMAS RITI, DIRECTOR, APPELLANTS AND CROSS-RESPONDENTS; MARY BOYD, INDIVIDUALLY AND ON BEHALF OF ALL OTHERS SIMILARLY SITUATED, RESPONDENT AND CROSS-APPELLANT, v. DEPARTMENT OF HUMAN SERVICES, ANN KLEIN, COMMISSIONER; DIVISION OF PUBLIC WELFARE, G. THOMAS RITI, DIRECTOR, APPELLANTS AND CROSS-RESPONDENTS; LENA CICCONE, RESPONDENT AND CROSS-APPELLANT, v. DEPARTMENT OF HUMAN SERVICES, ANN KLEIN, COMMISSIONER; DIVISION OF PUBLIC WELFARE, G. THOMAS RITI, DIRECTOR, APPELLANTS AND CROSS-RESPONDENTS; LAURA MATTHEWS, RESPONDENT AND CROSS-APPELLANT, v. DEPARTMENT OF HUMAN SERVICES, ANN KLEIN, COMMISSIONER; DIVISION OF PUBLIC WELFARE, G. THOMAS RITI, DIRECTOR, APPELLANTS AND CROSS-RESPONDENTS; FRANK COPPOLA, RESPONDENT AND CROSS-APPELLANT, v. DEPARTMENT OF HUMAN SERVICES, ANN KLEIN, COMMISSIONER; DIVISION OF PUBLIC WELFARE, G. THOMAS RITI, DIRECTOR, APPELLANTS AND CROSS-RESPONDENTS
- Cited By
- 122 cases
- Status
- Published